Philadelphia Releases Benzodiazepine Draft Guidelines for MAT

July 19, 2013

Important guidelines to help opioid treatment programs (OTPs) determine how to handle benzodiazepine use by their patients have been developed by the Institute for Research, Education and Training in the Addictions (IRETA) for the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIDS). Roland Lamb, MA, director of the DBHIDS Office of Addiction Services, talked with AT Forum about what the draft guidelines mean to OTPs who are struggling with ways to manage patients who use benzodiazepines while in medication-assisted treatment (MAT).

Although the guidelines were prepared under contract with DBHIDS for use by Philadelphia-area MAT providers, Mr. Lamb said they can be used by anyone—and he hopes they will be, when finalized. “This is a collaboration that went beyond Philadelphia,” he said. Partners were the Community Care Behavioral Health (CCBH) and the University of Pittsburgh in Allegheny County, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Pennsylvania Department of Drug and Alcohol Programs, he said. “We need to make sure the focus is on the disease of addiction and not just on managing medications. Methadone maintenance is so overregulated that it can become medication-focused, as opposed to treating people for their addiction.”

Treating Addiction

And while methadone maintenance is focused on opioid addiction, OTPs and all MAT providers must recognize that they are treating addiction per se, he said. “Once you have stabilized a person on methadone, you still need to pay attention to other issues.” Those other issues could include misuse of alcohol or other drugs, such as benzodiazepines

The concern for OTPs and patients is that benzodiazepines, in combination with methadone, buprenorphine, or any central nervous system (CNS) depressant, could result in respiratory depression and death. “There has been extensive writing about the synergistic effects,” he said.

But it’s not only about risk. Helping patients recover from addiction means counseling and a personal transformation away from seeking relief from drugs and alcohol.

“I believe that OTPs are failing their population if they don’t address addiction,” said Mr. Lamb. “It’s not just benzodiazepines, it’s everything.”

Lower Starting Dose, Inpatient Detox

One of the recommendations is for people on benzodiazepines to be inducted on a lower starting dose of methadone, but another is that all patients need an adequate starting dose. There seems to be a conflict between those two recommendations, but Mr. Lamb said that there isn’t. “What it really means is that you would need a longer lead time to get up to the optimal dose,” he said. “What you don’t want is to continue to follow through to the maximum dosage level, which could be 30 or 40 milligrams, at the onset of treatment,” he said.

The two recommendations are consistent when looked at together, because the main point is to ultimately get the patient up to the optimal dose. “In induction, they are in limbo, and will be struggling mightily to manage their addiction and perhaps find other means to do that,” he said. Some ways to bring patients up to optimal dosage and minimize the withdrawal symptoms that come with the very early days of induction for some is to provide a split dose during the day, to minimize the valleys, he said.

Another recommendation for patients who are using benzodiazepines is to taper their benzodiazepine use and then induct them into MAT. Sometimes, the best way to do this is inpatient detoxification, the guidelines state.

“It’s problematic that people think MAT is only done in an outpatient methadone program,” said Mr. Lamb. Philadelphia has established MAT across all levels of care. “We have people in residential treatment who receive MAT, as well as people who are in outpatient programs,” he said. “When a person isn’t responding to the outpatient milieu, you need to address the severity of the addiction.” And for OTPs, it may mean assessing the person as needing inpatient treatment. “‘If you didn’t have methadone, what level of care would this person be receiving?’ is a good question to ask,” he said.

Key Recommendations

The key recommendations of the IRETA report clearly state that use of benzodiazepines or other CNS depressants is not a contraindication for methadone or buprenorphine treatment—patients should not automatically be discharged from treatment because they are using benzodiazepines, either by obtaining prescriptions from other physicians or by buying them.

From the Recommendations:

CNS depressant use is not an absolute contraindication for the use of either methadone or buprenorphine in MAT, but is a reason for caution because of potential respiratory depression. Serious overdose and death may occur if MAT is administered in conjunction with benzodiazepines, sedatives, tranquilizers, antidepressants, or alcohol.

Individuals who use benzodiazepines, even if used as a part of long-term therapy, should be considered at risk for adverse drug reactions including overdose and death.

Many people presenting to services have an extensive history of multiple substance dependence and all substance abuse, including benzodiazepines, should be actively addressed in treatment.

MAT should not generally be discontinued for persistent benzodiazepine abuse, but requires the implementation of risk management strategies.

Clinicians should ensure that every step of decision-making is clearly documented.

There wasn’t always unanimous agreement among the participants in the development process for the guidelines, said Mr. Lamb. “We narrowed down the guidelines to what we had consensus around.”

Risk Management vs. Addiction Treatment

At the core of the consensus process was reconciling risk management with treatment of addiction, two goals that can be at odds with one another. But is there really any conflict? If the goal is recovery, then treatment of addiction should include dealing with craving and the problems of patients who are suddenly living without getting high.

There is a desperate need for this information, said Mr. Lamb. “We had a number of providers who were struggling with how to manage the use of benzodiazepines.” That’s the reason for the guidelines, and also the reason for a physician’s town hall sponsored by DBHIDS at the November conference of the American Association for the Treatment of Opioid Dependence (AATOD), to be held in Philadelphia.

“Some people have a legitimate need for an anti-anxiety drug,” said Mr. Lamb. “However, there has to be a limit to how far a provider goes, if there is no cooperation from the patient.”

Some patients start abusing benzodiazepines when they enter MAT because they are no longer able to feel euphoria from opioids, according to Mr. Lamb. “Part of the disease of addiction is the preoccupation with feeling good or feeling better,” he said, referring to euphoria and to minimizing withdrawal symptoms. Others come into treatment managing collateral emotional pain and psychic confusion, he said. “We’ve often found that the need to self-medicate is strong.” That’s why getting a patient stable on methadone is only the first step, he said. “That’s when the hard part begins.”

The early stages of treatment, when patients are no longer experiencing “feeling better” from opioids, are when other drugs, such as cocaine, alcohol, marijuana, or benzodiazepines, get introduced, said Mr. Lamb. “Chemistry is a way of life in our population, always finding new combinations to feel good and to feel better.” A new patient on methadone, once stable, won’t feel any signs of withdrawal, so the need to “feel better” will be gone. “But with this population there is always the need to alter one’s consciousness.” And there may also be depression and anxiety or legitimate mental illnesses, which methadone will not treat, and which require medication. But that doesn’t necessarily mean medications are always the answer.

When opioid-dependent patients begin MAT, they may also be going to other physicians who are prescribing medications for anxiety. “Hopefully the doctors are talking to each other, communicating in the best interest of the patient,” said Mr. Lamb. But the patient may want just the opposite. “Those in care are interested in keeping those two doctors separate, not wanting them to collaborate, because that will interfere with their goals.”